Laserfiche WebLink
SAN JOA0N COUNTY ENVIRONMENTAL HEALTH-11EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SVS .SE R V1 C F- fA000lo <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> SA htp <br /> FACLITY NAMEC /�cC�;t V Q <br /> SITE ADDRESS ,Y �-- ,� /"!.� A -!7 C k/TDr`+f iS�Z bS <br /> 264 i Sheat Number Direction Street Neme City 23p Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Strout Number Street Name <br /> CITY STATE ZIP <br /> PHOIIE#t Exr• APN# LAND USE APPLICATION# <br /> =7 1467-690 6 1 IS-1— -0Zo -- i I <br /> PHOHE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( } 06 6 <br /> CONTRACTOR/SERVICE REQ) NOL <br /> REQUESTOR Q�•T-�1qS0N HYJ0�A U L} C-3 ) ,1'v v CHECK if BILLINGADDRESSo <br /> PHONE# ExT. <br /> BUStNESSNAME -5R M� olp 4;:4--p S 2'3...rjJ�'C' <br /> HomE or MAILING ADDRESS ` _' p FAx# rt vy v <br /> ajw C> <br /> CITY N �^►�' w/ STATE C''�q ZIP p O; <br /> 31LLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> CouNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANTS SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT .® ey/�LT�igC�-/nI o <br /> IfAPPUCANT is not the BILLING PARTY.proof of authorization to sign is required Tt tl e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: (a,S 9LAV <br /> CotSl."ENfs: RECEIVM <br /> 3 �e, APR I02014 <br /> SAN JOAQUIN COUtM. <br /> ENVIROM..ENTAL <br /> HEALTH ,"Q <br /> ACCEPTED BY: EMPLOYEE M 'Z 6'1 DATE: 44 1D AP <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Compi d (if alrea ompleted): SERVICE CODE: 3 PIE: 2303 <br /> 'es Amount: 4 ( g$p , ct-0 Amount Paid ` Bp Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> A7/47nxt <br />